Liu Xingzhu, Mills Anne
Abt Associates Inc., Bethesda, Maryland, USA.
Hum Resour Health. 2005 Oct 27;3:11. doi: 10.1186/1478-4491-3-11.
With the recognition that public hospitals are often productively inefficient, reforms have taken place worldwide to increase their administrative autonomy and financial responsibility. Reforms in China have been some of the most radical: the government budget for public hospitals was fixed, and hospitals had to rely on charges to fill their financing gap. Accompanying these changes was the widespread introduction of performance-related pay for hospital doctors--termed the "bonus" system. While the policy objective was to improve productivity and cost recovery, it is likely that the incentive to increase the quantity of care provided would operate regardless of whether the care was medically necessary.
The primary concerns of this study were to assess the effects of the bonus system on hospital revenue, cost recovery and productivity, and to explore whether various forms of bonus pay were associated with the provision of unnecessary care. The study drew on longitudinal data on revenue and productivity from six panel hospitals, and a detailed record review of 2303 tracer disease patients (1161 appendicitis patients and 1142 pneumonia patients) was used to identify unnecessary care.
The study found that bonus system change over time contributed significantly to the increase in hospital service revenue and hospital cost recovery. There was an increase in unnecessary care and in the probability of admission when the bonus system switched from one with a weaker incentive to increase services to one with a stronger incentive, suggesting that improvement in the financial health of public hospitals was achieved at least in part through the provision of more unnecessary care and drugs and through admitting more patients.
There was little evidence that the performance-related pay system as designed by the sample of Chinese public hospitals was socially desirable. Hospitals should be monitored more closely by the government, and regulations applied to limit opportunistic behaviour. Otherwise, the containment of government financing for public facilities may result in an increase in the provision of unnecessary care, an increase in health costs to society, and a waste in social resources.
随着人们认识到公立医院往往存在生产效率低下的问题，全球范围内都进行了改革，以增加其行政自主权和财政责任。中国的改革最为激进：公立医院的政府预算是固定的，医院不得不依靠收费来填补资金缺口。伴随着这些变化的是，医院医生广泛实行了与绩效挂钩的薪酬制度——即“奖金”制度。虽然政策目标是提高生产率和成本回收率，但增加医疗服务量的激励措施可能会在无论医疗服务是否必要的情况下都发挥作用。
本研究的主要关注点是评估奖金制度对医院收入、成本回收和生产率的影响，并探讨各种形式的奖金支付是否与提供不必要的医疗服务有关。该研究利用了六家样本医院的收入和生产率纵向数据，并对2303例追踪疾病患者（1161例阑尾炎患者和1142例肺炎患者）的详细病历进行审查，以确定不必要的医疗服务。
研究发现，随着时间的推移，奖金制度的变化对医院服务收入和医院成本回收的增加有显著贡献。当奖金制度从激励较弱的增加服务制度转变为激励较强的制度时，不必要的医疗服务和入院概率都有所增加，这表明公立医院财务状况的改善至少部分是通过提供更多不必要的医疗服务和药品以及收治更多患者实现的。
几乎没有证据表明中国公立医院样本所设计的与绩效挂钩的薪酬制度符合社会期望。政府应更密切地监督医院，并实施相关规定以限制机会主义行为。否则，政府对公共设施资金投入的控制可能会导致不必要医疗服务的增加、社会医疗成本的增加以及社会资源的浪费。
